Regaining power through construction of identity?

Word frequency query of transcribed interviews

Master’s Programme in Social Work and Human Rights Degree report 30 higher education credits

Spring 2014

Author: Annika Ekenja

Supervisor: Helena Johansson

Regaining power through construction of identity?

Experience of Multisystemic Therapy from a Youth’s Perspective

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Acknowledgments

Thank you to my supervisor for inspiring discussions and support in the process of this work.

Thank you to the participants of this study. Without your participation it would not have been completed.

Thank you to Emma for giving me access to participants and supporting my research. Thank you also to the different MST teams in Sweden for their cooperation.

Thank you to Kajsa, Magda, Consolée and Tracey for their support, motivation and inspiration.

Thank you to Daniel for your encouragement, your support and just always being there.

Abstract

Literature and studies exist on how to create services in the best interest of the client or how these services have an impact on individuals. They are however mainly from a social work professional stand point and rarely from how clients would develop and create the services that can imply a life change for them. Especially when working with children under 18 years old issues of agency and age that can result in the disregard of the Convention on the Right of the Child (UNCRC). The target group of this study is therefore youth between the ages of 15 to 17 years old in three cities across Sweden to allow them to voice their opinion and experience of being in treatment. Resulting from that is the aim of this study – to investigate how an intensive treatment method like Multisystemic Therapy is described from a client’s point of view. Does the fact of being treated within the social service system influence the client’s self-perception, creation of identity or relationships? Finding out how intervention methods influence the social world and social being of individuals and how this can be used to improve social work practice is in centre. Throughout qualitative interviews with three male persons in Sweden an in-depth understanding had been able to be obtained by a combination of narrative and thematic analysis. Major results had been that the construction of identity is influenced by the fact that they are currently in treatment and even more by the expectations of their surroundings and the society. Even though the treatment process is shaped by power hierarchies the youth had been able to develop own mechanisms to regain power of the identities they were assigned to from outside or society. Interestingly enough the youth described the close relationship with the therapist and the intensive attendance by the social worker through setting up rules for example as positive and guiding for their family life. The findings within this study have an implication on how to further develop the client- social worker relationship in youth and family welfare settings.

Title: Regaining power through construction of identity? – Experience of Multisystemic Therapy from a youth’s perspective.

Author: Annika Ekenja

Key words: construction of identity, power, youth, Multisystemic Therapy, Sweden, Social

Construction.

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Table of contents

Acknowledgments ... i

Abstract ... i

Abbreviations ... iv

1. Introduction ... 1

1.1 Research questions and aim ... 2

1.2 Multisystemic Therapy – a short overview ... 3

2. Recent debate and literature on MST ... 5

2.1 Findings on current research on MST ... 5

2.2 Own conclusion on the Henggeler and Littell dispute and implications for further research ... 6

2.3 Summarising findings of the literature review on MST ... 7

3. Relevant studies and theoretical concepts ... 10

3.1 Origin and different forms of the theoretical concept social construction ... 10

3.2 Construction of ‘clienthood’ in social work ... 12

3.3 Construction of ‘deviant’ identities in social science discourse ... 13

4. Theoretical framework ... 15

4.1 Theories of power relevant in social work ... 15

4.2 Nikolas Rose and the construction of identity ... 18

5. Methodology... 21

5.1 Interviews ... 21

5.2 Sampling and participants ... 22

5.3 Issues of access to participants ... 23

5.4 Limitations and ethical issues ... 23

5.5 Validity, reliability, generalization or how to evaluate qualitative work ... 25

5.6 Method of analysis ... 26

6. Analysis and Findings ... 29

6.1 Terms, definitions and stereotypes ... 29

6.2 Mum & Dad – parents ... 30

6.3 Key words ... 33

6.4 Treatment method ... 35

6.5 Power... 38

6.6 Relationships ... 40

6.7 Self – perception... 43

7. Concluding discussion ... 46

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References ... 50

Appendix 1 – Summary of randomised studies on MST ... 58

Appendix 2 – Interview guide ... 59

Intervjuguide Swedish ... 60

Appendix 3 – Interview request MST team ... 62

Interview request participants ... 66

iv

Abbreviations

ADHD – Attention Deficit Hyperactivity Disorder APA – American Psychiatric Association

CAQDAS – Computer Assisted Qualitative Data Analysis Software COE – Council of Europe

CYSR – Children and Youth Services Review

DSM – Diagnostic and Statistical Manual of Mental Disorders EBP – Evidence Based Practice

FSRC – Family Services Research Centre

IBSS – International bibliography of the social sciences MST – Multisystemic Therapy

OHCHR – Office of the High Commissioner for Human Rights ProQuest – Social Service Abstracts

TAU – Treatment-as-usual UK – United Kingdom UN – United Nations

UNCRC – United Nations Convention on the Rights of the Child

UNESCO – United Nations Educational, Scientific and Cultural Organization UNODC – United Nations Office on Drugs and Crimes

US – United States

1. Introduction

Having a background and education in social work and practice in Germany as well as working with children and young adults in social services raised a special interest in how clients actually experience what is carefully planned for them. When considering the long and short term impact of the client’s treatment plan, the main ethical and professional concern is how power relations are perceived and interpreted. This dilemma has always been part of the researcher’s practice. Questions that accompanied the researcher’s professional practice where mainly around if what is done is making a difference and how clients can be included more into the decision – making process that is affecting their life.

There is a considerable amount of literature and research regarding how social work professionals perceive the implementation of an intensive treatment method like Multisystemic Therapy (MST) in varying countries as well as in Sweden. The advantages and disadvantages of such high need intervention methods in a Scandinavian context have recently been targeted in research (Gustle, Hansson, Sundell, Andrée-Löfholm, 2008; Sundell, Hansson, Andrée-Löfholm, Olsson, Gustle, Kadesjö, 2008; Andrée-Löfholm, Brännström, Olsson, Hansson, 2013). However, little has been done to investigate how service users who are receiving MST perceive these intervention methods and how they construct and describe relationships outside and inside the treatment. Therefore the overall aim of this study will be to find out through qualitative data collection how social work practice is perceived from a client’s point of view and how this affects other areas of their life. The research objective therefore will be on youth from the age of 15 to 17 years old with so-called ‘antisocial’

behaviour and how they experience an intensive treatment method like Multisystemic Therapy in Sweden.

To this point research in the field of MST is focussing mainly on how Swedish social workers evaluate the method or if it is cost effective (Healy, 2000; Gustle et al, 2008).

Additionally quantitative research is predominant in this field which does not allow an in- depth understanding of complex intervention process. In Sweden MST had been implemented into social welfare practices around 2005. Randomized control trials were conducted with the aim to investigate the transportability of MST to a Swedish context. Findings show that no significant differences in treatment outcomes can be found in comparison to other social services (Gustle et al, 2008).

Researching how young adults who are the target subject of these methods experience them is rarely done. A Dutch study points into a guiding direction by stating that research has to focus more on the experience of the target group itself (Asscher et al, 2013). They note in their results no change in self-esteem for the youth and an increased sense of personal failure appeared during MST treatment. The lack of existing research within the target group might be due to the fact that children or young adults in these interventions are often underage, in precarious and traumatizing situations and difficult to access for research. Due to these ethical concerns the focus will be on the age group 15 to 17 years old since it allows me to access them without consent from parents or others. The advantage of this age group will be to get insights and information from the young adults directly without influence or interference. The issue of pre-selection by professionals still remains since they might chose youth with whom they have a positive contact / relationship. Adding to that the experience of being treated is rarely investigated from a youth’s point of view. Vitus (2014) found in a very recent study that youth want to be more included in decision making processes, want to be respected and the feeling that their opinion has an impact. Finding out how youth in this study perceive equality and power issues will be of special interest therefore.

To be able to fully understand how such an intensive method influences clients self –

awareness and construction of their identity, an investigation from a client’s perspective is

needed. This study aims to investigate the mentioned aspects from three individual’s point of

view in a highly specified context. The extent to how language is used and relationship between client and social worker is constructed will be part of the theoretical and analytical framework. The above mentioned research objectives are important for further developing social work practice towards a more client centred practice and to complement quantitative research for a more in-depth understanding of complex intervention processes. Similar research had recently been done by Tighe et al (2012) to investigate youth and families perception on MST in the UK to improve clinical practice. Following this focus, research is needed on experience of youth in Sweden and how the method influences their self – awareness. This is especially intriguing since studies in Sweden have proved no difference in treatment outcomes when compared to treatment as usual and studies in the UK and The Netherlands show negative effects negative effects on individuals’ relationships. Due to the neglect of current research to address the clients’ point of view regarding the impact of their treatment on familial relationships and self-awareness this research will focus on their view and how the whole treatment process affects their self-awareness.

The first chapter will allow the reader to understand the research questions guiding the data collection and what MST is in general as well as how it can be located within the Swedish context. Since MST as a method was founded in the United States (US) chapter two will include literature about its treatment effectiveness, major findings and disagreements in the US as well as some European countries. Following this will be chapter three where an overview of recent debates within the field of youth and social work is shown. Chapter three is important since it allows an insight; supported by the theoretical concept of social construction, how youth is being constructed in recent literature and what kind of concepts are used to describe the age group. Within chapter four different aspects of theories in social science which build the theoretical framework are being presented. Mainly theories of power and the construction of identity are being investigated since these are most relevant when looking at youth in a social work intervention which is shaped by power imbalances. The theoretical framework in chapter four is supported by theories, concepts and literature in chapter three and together these two chapters will be used as a tool to look at the collected data. Chapter five then explains the methodological approach to access data. Subsequently will be chapter six – a presentation of the analysis and findings within the data set. Here the different nodes that were created within the analysis are being used to structure findings and will be followed by a summary of the most relevant findings in respect to the research questions. The last chapter seven will include a conclusion and discussion of the research. In the appendix the interview guide and the interview request can be found.

1.1 Research questions and aim

The aim of this study is to investigate how social work practice is perceived from a client’s point of view and how this affects other areas of their life. Youth age 15 to 17 years old will be interviewed in Sweden to be able to obtain a client’s point of view and based on that develop social work practice further.

1. How do youth experience an intensive treatment method like Multisystemic Therapy (MST)?

 How do they describe being treated / being a client / being ‘antisocial’

from their perspective?

2. How do they construct and describe relationships outside and inside the treatment?

 How do they describe the treatment method and how do they position themselves in it?

 How can service users’ involvement be understood in this context and

how does it have an influence on social work practice?

1.2 Multisystemic Therapy – a short overview

Multisystemic Therapy is a treatment method that can be located within the category of Evidence – Based Practices (EBP) and has its origins in the United States around Dr. Scott Henggeler. He created the method around the 1990’s in accordance with forming the Family Services Research Centre (FSRC) at the Medical Centre of South Carolina, United States. In 1996 a university licensed organization called MST Service was created to spread the method since it became more and more successful according to the FSRC. To ensure quality and the positive outcomes promoted by Henggeler, MST Services offered help setting up and carrying out MST in different communities and cities in the U.S. resulting in licensed training programs (MST Services, 2014g). Today the MST model is disseminated in the U.S. and most of Western Europe.

MST is an intensive, short – term family – and community-based form of treatment to work on serious antisocial behaviour in youth. The approach targets the multiple needs of serious juvenile offenders and their families to avoid out-of-home placement and addresses the different factors that are related to youth delinquency. According to the method it meets the youth and their families in their natural setting such as schools, family homes or the neighbourhood to support positive social behaviour and avoid negative behaviour. Duration of interventions depend on the individual need of the individual but are never longer than four to six months. Considering that the youth is living in different systems such as their families, school or friends that are interconnected, the approach uses a so called ecological model.

Through that approach, interventions do not only target the child or youth, but also include other systems that can be linked to the antisocial behaviour. MST intervention techniques are empirically-based on cognitive behaviour therapy, behavioural parent training and pragmatic family therapies (MST Services, 2014a). Some of the goals of MST are to provide parents with tools and resources to address challenging behaviour; to decrease criminal activity in youth; to reduce antisocial behaviour; to invoke resources within families, friends and communities to support a long term behavioural change and to be cost effective by decreasing incarceration rates and out-of-home placement (MST Services, 2014b, e).

Due to the fact that MST is “[…] a home-based model of service delivery […]” (MST Services, 2014c) it removes barriers such as transportation, time or location to access services.

Interventions and services include the whole family as well as other influential people and are claimed to be highly individualized to ‘fit’ the family’s needs, strengths as well as weaknesses. Mechanisms to ensure quality and treatment outcomes are a treatment manual created by the developers Henggeler, Schoenwald, Borduin, Rowland and Cunningham themselves; nine treatment principles; supervision and consultation for treatment teams; on- going intensive clinical training for teams and continuously treatment evaluations from different perspectives as well as follow-up evaluation and studies (MST Services, 2014b, d, e). The nine treatment principles are:

- Finding the ‘fit’

- Positive and strength-focused.

- Increasing responsibility.

- Present-focused, action-oriented, & well-defined.

- Targeting sequences.

- Developmentally-appropriate.

- Continuous effort.

- Evaluation and accountability.

- Generalization (MST Services, 2014f).

Further on MST Services states that interventions used in MST are “[…] scientifically-based,

goal-oriented and problem-focused” (MST Services, 2014c).

In Sweden MST is part of the social services agency (Socialtjänsten) and is organised and located within the local city council. Families and youth can either contact MST directly and enquiry for assistance or are referred to it by Socialtjänsten, social workers or teachers. In Sweden there are currently eleven MST teams operating. Sweden signed the UNCRC which influenced the use of a rights perspective within the state’s child welfare policies. Youth and children have the right to good living conditions, health, social and financial security (Office of the High Commissioner for Human Rights (OHCHR), 1990; Council of Europe (COE), 2011). The Swedish Government also adopts the perspective that children and youth should be able to participate and be involved in decisions regarding their lives as well as the environment and society around them. How youth in the end experience involvement in decision making and their own position within their surroundings or society will be investigated in this thesis.

Participation in and assistance by the social services agency is always voluntary to a

certain degree (Janson, 2004). Most welfare services for youth are provided by the public

sector in Sweden. All services offered have to be in the best interest of the child according to

the UNCRC.

2. Recent debate and literature on MST

The purpose of a literature review is to identify and interpret what is known about the research topic up to date. Fink (2010) highlights four key words how a high – quality literature review should be: “[…] systemic, explicit, comprehensive and reproducible […]”

(Fink, 2010: 15). The researcher has to systematically examine all sources that could be of use for the review and clarify explicitly reasons for that. On account of this other researchers will be able to reproduce the methods used. Information should only be extracted from original studies, experiments or observations with a clear study design, explicit research objectives, a distinct research plan, precise data analysis and interpretation (Fink, 2010).

One of the first steps when conducting a literature review is to find out what is exactly needed for the study or research to further develop. The researcher has to be very precise to not just find a vast amount of literature but to be able to identify relevant information. By doing a review the key concepts important to the research questions should be identified and unanswered questions elicited. Four central questions will be answered in this literature review on MST in dependence with Bryman (2012: 98):

- What is known about the experience of youth in MST and how is it used in social work practice?

- What kind of research design is mostly applied to investigate?

- What are main controversies on MST?

- Do inconsistencies exist in findings and are there unanswered questions?

Literature had been obtained through different channels: books, journal articles, databases and current public articles. Three databases were accessed through the library system of Gothenburg University, namely International bibliography of the social sciences (IBSS), Social services abstracts (ProQuest) and the SAGE Handbook of social work research (SAGE knowledge).

Key words used to find articles or books related to the research objectives are:

- Youth* / young adult* / adolescent* / youngster* four different terms will be used because the definitions of how the age group specific to this research is called vary.

- Multisystemic therapy, power, language, “power of language”, social work, Michel Foucault, Nikolas Rose, experience, participation, social construction, perception, clientization, categorization, governmentality, intensive treatment method*, evidence based practice*, service user* involvement.

2.1 Findings on current research on MST

MST as a method and approach had been strongly researched over the past twenty years and is considered as one of the few empirically supported treatments. In fact the United Nations Office on Drugs and Crimes (UNODC) published a list on ‘Evidence-Based Family Skills Training Programmes’ in 2009 where different programmes were reviewed as guidance for policy-makers, Non-Profit Organizations (NPO) and programme managers. They presented different methods in descending order of the level of scientific evidence on which they were based. MST is ranking on place eight out of twenty-four and with that in the first third of the listed effective treatments. Unclear however is, if the UNODC reviewed and cross checked the evidence themselves or if they just based it on the studies and trials provided by MST and others assuming that they were scientifically correct. The level of evidence indicated by the UNODC is four independent randomized control trials, twelve randomized control trials, two quasi experimental studies and two studies based on pre- and post-intervention evaluation (UNODC, 2009:38). This level of evidence is being questioned by researchers around Dr.

Julia H. Littell (2005) in the journal ‘Children and Youth Services Review’ (CYSR). The

CYSR is an interdisciplinary forum for critical scholarship regarding service programmes for

youth and children and had been accessed through the library system of Gothenburg University.

The initial access to the article (‘Lessons from a systemic review of effects of multisystemic therapy’) published by Littell in 2005 had been by key word search of ‘MST’

and ‘multisystem* therapy’. Only peer reviewed articles had been chosen, not older than ten years unless the primary source had been older and in English language. Various articles found through this approach, indicated a critical exchange between Littell (2005&2006) and the developers of MST around Dr. Scott Henggeler (Schoenwald, Borduin, Swenson, 2006).

Littell states in her first article, which had been available online already in December 2004, that a “[…] systemic review of results of controlled studies of the effects of multisystemic therapy (MST) points to inconsistent and incomplete reports on primary outcome studies, important variations in implementation and integrity of randomized experiments, errors of omission […]” (Littell, 2005: 445) and findings that are different from previous reviews. The author based this statement on applying the method of a systemic review according to the work of the Campbell Collaboration

and revealed in great detail her search methods. The description and definition of a systemic review by the Campbell Collaboration corresponds with other sources such as Bryman (2012). Findings and results are well reasoned, clearly presented and especially point out the conflicts of interest when developers research their own method. In this case it is of special interest because funding for research and MST services is at risk when finding negative results since MST Services is a national corporation. The response by Henggeler et al in 2006 is accordingly. Following this there is one more response by Littell (2006) to Henggeler et al (2006) which ends with the conclusion that MST and EBP have to be open to critical assessment of evidence used and being able to revise and incorporate new findings.

2.2 Own conclusion on the Henggeler and Littell dispute and implications for further research

Being able to read a written and clearly worded dispute on two side of MST had been very useful to get an inside view and first impression into the current discussion on MST and EBP.

It allowed the researcher to get an idea about what studies are important on MST and EBP, and argumentation being used on both sides. Another effect however was, to not invest too much time into figuring out who is right and who isn’t. Who is using more valuable references and are accusations true or not?

Finding out about this dispute early in the research process additionally made clear that a more narrowed down searched on MST had to be done. Three limitations to further research had been applied. First, the key word MST / multisystem* therapy was searched for in connection with Sweden, Norway, United Kingdom (UK) and Netherlands since these are the four European countries where MST had been disseminated and researched early on.

Second, articles and research studies were limited to the date of issue not being older than 2008. Lastly, only literature in English language was used. These decisions were made because the dispute by Henggeler et al and Littell portrayed major studies of the implementation and effectiveness on MST in Norway, Canada and the U.S. and used these extensively to discuss and critique each other. The mentioned studies by Cunningham (2002) in Canada and Ogden & Halliday-Boykins (2004) in Norway for example were acknowledged but are not going to be used in this research. The studies by Cunningham (2002) and Sundell, Hansson, Andrée-Löfholm, Olsson, Gustle and Kadesjö (2008) in Sweden did not replicate

1 “Campbell Systematic Reviews is the peer-reviewed online monograph series of systematic reviews prepared under the editorial control of the Campbell Collaboration. Campbell systematic reviews follow structured guidelines and standards for summarizing the international research evidence on the effects of interventions incrime and justice, education, international development, and social welfare.”

(Retrieved on February 17, 2014 from http://www.campbellcollaboration.org/lib/?go=monograph).

the effectiveness findings of previous studies conducted by Henggeler et al (1992, 1997, and 2002). Whereas the short-term effectiveness study by Ogden & Halliday-Boykins (2004) in Norway displayed similar positive effects of MST compared to TAU (Asscher, Deković, Manders, van der Laan, Prins, 2013; Andrée-Löfholm, Brännström, Olsson, Hansson, 2012).

Part of limiting literature research is that the research objectives of this study focus on youth and their experience and not on the effectiveness of MST in Sweden. Furthermore these studies and trials had been intensively studied, reviewed and critiqued, that the decision was made to focus on more recent literature. Eleven studies met the applied criteria of limitation.

On that account four

studies were chosen reflecting different aspects of MST and its dissemination in Sweden such as the transportability, cost-effectiveness, practitioner’s view or issues of interpreting MST to treatment-as-usual (TAU). The selection was made based on perceived relevance when looking through abstracts found by the above mentioned key word search. Three

recent studies from the US and the developers of MST were chosen to allow a comprehensive picture with different perspectives. Four

more studies conducted in the UK and the Netherlands on implementation and cost-effectiveness were chosen to get a broader picture about the situation in Europe.

Including the Henggeler-Littell dispute all eleven studies reflected four themes: I.

Henggeler-Littell dispute; II. meta-analysis of MST by Curtis, Ronan and Borduin (2004) in the U.S.; III. current studies on MST in a Swedish context and IV. current studies in the UK and Netherlands.

The importance of well investigated and thorough research on a certain phenomenon became apparent when seeing through the current literature on MST and EBP. In the end it comes down to a handful of studies and research trials that other authors refer to and build their research on. Due to this fact the table in a very recent article by Andrée-Löfholm et al (2013:

29) had been used to get an overview on randomised studies on MST. The table includes a summary of studies such as early research done by Henggeler et al (1992 up to 2009), Cunningham (2009), Ogden & Halliday-Boykins (2004) or Sundell et al (2008). It includes information on the research context, country, population, follow-up and description on the comparison group (Appendix 1).

2.3 Summarising findings of the literature review on MST

The findings of all articles considered in the literature review on MST were written down in a mind map to be able to detect similarities and inconsistencies in them. This approach resulted into five main themes listed in descending emergence: treatment fidelity, contextual circumstances, association with deviant peers, cost-effectiveness and impact on relationships.

Treatment fidelity: Across all four themes treatment fidelity is mentioned as the most crucial aspect influencing treatment outcomes. The meta-analysis by Curtis et al (2004) places four demands in their conclusion on how to improve the MST method. Treatment fidelity is mentioned as the first area of improvement since outcome differences in efficiency and effectiveness studies where found. Henggeler et al (2005) state in their comment on Littell (2005) that a conceptual and methodological mistake in her review had been to not take into account what effect treatment fidelity can have on effectiveness outcomes. Gustle et al (2008) then pick up the issues of treatment adherence in their motivation why research has to be done on social work professionals’ views on EBP and MST in Sweden. When looking at the research by Sundell et al (2008) on transportability of MST in Sweden, the importance of treatment fidelity is specifically highlighted in their conclusion.

2 Andrée-Löfholm et al, 2013; Gustle et al, 2008; Sundell et al, 2008; Olsson, 2010.

3 Curtis et al, 2004; Henggeler et al, 2009; Henggeler, 2004.

4 Asscher et al, 2013; Cary et al, 2013; Jansen et al, 2013; Tighe et al, 2012.

Concluding one can say that adherence to the treatment method is significant for the effect of MST across countries.

Contextual circumstances: The issue of site effects and different national contexts comes to attention as the second most apparent theme in the literature review. Again Henggeler et al (2005) describe the different contexts MST had been tested in the U.S. and Europe as an explanation for variances in treatment outcomes. Contextual circumstances therefore can be the composition of the population at a site (noted in all four themes), different set up of youth welfare services (Sundell et al, 2008) and the role MST plays in the U.S. as an important alternative to regular youth welfare services (Olsson, 2010). All studies conducted in Sweden mention contextual circumstances as a possible explanation for the fact that MST does not achieve similar results as studies on effectiveness in the U.S. or Norway.

Directly connected to that is the finding by Asscher et al (2013) in The Netherlands that the quality of youth services available in a country is affecting treatment outcomes. For example are deviant youth in the U.S. treated in the juvenile justice system where participation is forced in one way or another. In contrast to that the treatment of deviant youth in Sweden and most of Europe is located under youth and child welfare offices where participation in treatment is voluntary and recommended as an option to the juvenile justice system. Another common explanation given in literature on MST in Sweden is that, whereas in-home treatment is something almost exquisite to MST in the U.S., it is much more frequently used in Sweden. Lastly one can refer to the research by Andrée-Löfholm et al (2013) on the importance of TAU as a comparator in European effectiveness studies. The quality of TAU and interventions by social welfare services are important to consider since they heavily influence the outcome of an effectiveness study.

Association with deviant peers: this theme is the only one where inconsistencies were found in literature findings. Studies conducted in the U.S. came to the conclusion that MST is proven affective when it comes to reducing the association with deviant peers (Curtis et al, 2004). However the authors point out in their findings that, measurements to better assess association with deviant peers have to be installed in studies and the MST method.

Studies conducted after that seemed to have developed these measurements or control mechanisms with varying results. Asscher et al (2013), Tighe et al (2012) and Sundell et al (2008) interpret the results of their findings as the method not being effective when it comes to the association with ‘antisocial’ peers. The close connection between deviant peers and the willingness and ability to change behavioural issues is important to consider. If the contact with deviant peers is identified as a factor of continuing deviant behaviour (Tighe et al, 2012;

Henggeler et al, 2009; Asscher et al, 2013) than a focus of treatment has to be supporting to develop an alternative peer group since just separation from the peer group will not be an option to sustainable treatment. Creating tools youth can rely on when peer pressure is occurring is important to be able to discover the link between association with deviant peers and their own problems. Otherwise change will be hard to achieve and maintained. This idea is however contradictive to the short-term treatment idea of MST, since working on changing association with peer groups will not be able to be achieved within four to six months.

Especially for children and youth peer groups are essential for their development and strongly

influence their behaviour. Youth peer groups are quite often the focus of social policies and

social control mechanisms from outside like the police. The importance of peer groups and

affiliation to a social world for creating social identity in socialisation processes has to be

considered when targeting deviant peer groups. Social world describes the correlation of

children’s and youth’s life as a social group or peer group in relation to the adult world. They

structure their identities based on the demands of their peer groups, adults and relationships

with friends through games or interactions (James & James, 2008). Why should the youth

then give up a group which has provided them with an identity and a sense of belonging?

Cost-effectiveness: MST as a method is proven and advertised in the U.S. as a cost- effectiveness method (Henggeler et al, 2014 a-f). In Sweden as well as in UK long-term studies are not yet available due to relatively short time of MST being implemented into social services. The cost-effectiveness study in Sweden bases their data on a two year period and concludes that MST is associated with a net loss to society (Olsson, 2010). Possible explanation by the author is the high average costs in implementing and providing MST.

Therefore future cost-effectiveness studies have to be conducted to evaluate the financial aspect. The British study from Cary (2013) states that MST can be cost-effective when it serves as a complement to other services. Since this study exhibits several limitations further research has to be conducted in the UK. A current study is being conducted on the cost- effectiveness of MST in The Netherlands by Jansen et al (2013).

Impact on relationships: Generally there seems to be consent about the positive impact of MST on relationships in all four themes (I-IV). An important part in this improvement is a more positive and fruitful communication between all the parties involved.

Tighe et al (2012) for example report that parent’s confidence and family relations increase throughout treatment which has an impact on how they relate to their children. In correlation to that a strong relationship with the therapist is regarded as a source of support that proves to be effective for the relationships within a family (Tighe et al, 2012; Asscher et al, 2013).

Subsequently one can conclude that when it comes to improved family relations, studies on effectiveness have similar findings disregarding the context they were conducted in.

Coming back to the four questions asked at the beginning of this chapter: What is known about the experience of youth in MST and how is it used in social work practice? What research design is mostly applied to investigate? What are main controversies on MST? Do inconsistencies exist in findings and are there unanswered questions?

One qualitative study had been reviewed that investigated youth’s and parents’

experience on therapeutic processes and outcomes in MST treatment (Tighe et al, 2012). Only one representable study had been found that focused on service users’ view on MST and proves true how important it is to investigate highly complex, personal and psychological processes to be able to gain a better understanding how intervention methods affect the ones they are targeting. A direct connection how this is influencing social work practice could only been found in the aim of the authors to improve interventions methods and clinical practice.

Because almost all other literature found is of quantitative nature and focuses on the question whether MST is effective and cost-beneficial or not, the importance of this research is once more highlighted.

Inconsistencies in findings were mainly located within the area of MST being effective for association with positive peer groups or vice versa association with deviant peers. Studies conducted within different contexts report different findings.

Probably the main public controversy exists between Littell (2005, 2006) and

Henggeler et al (2005) and brings out the difference of opinions on EBP. The same way EBP

becomes more and more common and popular in European contexts at the same time the

opposition towards EBP in social work grows. This is linked to another controversy found in

reviewing literature. Different opinions exist whether MST can be implemented in different

contextual circumstances and can achieve the same outcomes claimed by the MST Services

Inc.

3. Relevant studies and theoretical concepts

The concept of seeing children as independent social actors did not emerge until the 1970’s in social studies. It shifts the focus from not recognizing children as full human being and passive parts in society towards their ability to have some control of their life and existence and the important role they (can) play in our society. From a sociological perspective Émile Durkheim and Karl Marx debated about the extent to what individuals can act independently of the social structures and societies they live in. Since then studies on children’s agency had been investigated to different extents. To find out how youth in MST settings are able to exercise their agency and the successive effect it has is therefore part of this research. James and James (2008: 9) describe agency as “[…] the capacity of individuals to act independently […] ”.

According to the United Nations Convention on the Rights of the Child (UNCRC) a child is defined as a person under the age of 18. In different countries the age a child can be legally held accountable varies from ten to 15 years. However in terms of welfare systems legal guardians can still make decisions up to the age of 18 what is in the best interest or not.

So in one way others can decide over you and your life until you are 18 years old but if you get in legal trouble and you are over 15 years for example you are self – responsible. That dilemma and contradiction is been represented in literature when it comes to defining age.

The UNCRC is trying to avoid that dilemma by stating that the child always has to be included in decisions affecting their life (Kassem, Murphy & Taylor, 2010).

In studies many varying definitions, ideas and concepts about childhood, adolescents and young adults were found. The definitions vary according to age group or specifications and competences assigned by authors. Based on these different inputs the decision was made to call the age group of focus (15 to 17 years old) youth* or young adults. This expression was chosen because it represents more the transition from being a child to being an adult and having to deal with life changing problems and decisions. It also reflects the definition made by the United Nations (2003) that youth are people between the age of 15 to 24 years old as well as the definition made by James & James (2008). They base their definition on western industrialised nations which socially construct youth according to the chronological period of 13 to 18 years old as well as physical and social development. Being 15 years old in Rwanda or Vietnam is different than being 15 in Sweden or Germany. These two definitions were applied as justification for using the word youth for the targeted age group of this research. In my opinion they both best explain and unite the mentioned above reasons of social development as well as transition into adulthood in an industrialised nation like Sweden.

3.1 Origin and different forms of the theoretical concept social construction

The literature search on ‘Social Construction’ revealed that the concept had been very popular

around the 1970’s to 1990’s in psychology and not so much in social work. Just over the past

twenty years an increase in articles that relate their analysis in social science to social

construction can be found in two databases – IBSS and ProQuest. When narrowing down the

search result to Social Construction* / Social work / Youth* mainly articles with topics of

youth’s construction of gender, sexuality or for example ethnicity came up. When looking at

the combination Social Construction* / Youth* / Identity a prevalence for construction of

identity in psychiatric settings or ethnicity was noted. Investigating the correlation of Social

Construction* / Youth* and Power wasn’t as fruitful as anticipated. From all three search

combinations only scholarly articles were picked not older than ten years to allow an insight in recent development in the field of social work.

The most influential and biggest contribution in the emergence of social constructionism had been by Peter L. Berger and Thomas Luckmann in their book ‘The Social Construction of Reality’ 1967 in New York, U.S. Their basic argument is that “[…] reality is socially constructed and that the sociology of knowledge must analyse the process in which this occurs.” (Berger & Luckmann, 1967: 13). The everyday life of individuals is a reality in itself that is subjectively interpreted by them as a harmonious world and adhered to through their own ideas and human activity in it. They reflect the fourth theme (iv.) of Burr’s key assumptions that individuals create together in daily interactions social phenomena and then continuously sustain them through social practice. At the same time as people are constructing the world around them and their identity in it they perceive it as pre-given and static (Burr, 2003; Berger & Luckmann, 1967).

“The social processes involved in both the formation and the maintenance of identity are determined by the social structure” (Berger & Luckmann, 1967: 173). Based on that statement identities are shaped by interplay of social structure, individual consciousness and an interdependency of various indicators such as family, cultural or ethnic background etc. In relation and reaction to the existing social structure an identity is being maintained, changed or assimilated (Berger & Luckmann, 1967: 173). Identity can therefore be seen as a phenomenon which emerges out of the interaction between and individual person and the society he or she lives in. Theories about identity always have to be seen in the theoretical framework, specifically theories about reality they are created in since they might have a different effect on them. Berger and Luckmann describe theories about identity as a social phenomenon specific to a certain context.

A more current view on the concept of social construction can be obtained by the SAGE Encyclopaedia of Social Science Research methods by Lewis-Beck, Bryman and Liao (2004). They state that it cannot be seen as a defined set of principles but rather as a continuous conversation on the nature of knowledge and how individuals and societies understand the world around them. This view is reflected in Burr’s (2003) book on Social Constructionism that no single definition or description of the concept exists and that it is mainly used in psychology. Since social work is influenced and builds on theories of psychology, as mentioned before, it is relevant for this research. Over the last years the theory had been further developed and been used in different contexts. It is seen as an important description of how knowledge is being generated in a scientific way as well as in society. As a theory of how individuals ‘function’ it offers an alternative to traditional ways of seeing psychological and individual processes. The way people understand the world depends on the interactions with other people and the sense they make out of them. Precisely because of that this theory is so important to analyse the elicited data of this research and how youth do understand or construct the world around them.

Burr (2003: 2-5) identifies four recurrent features and key assumptions that occurred in different approaches and concepts of social constructionism over the years. These key assumptions will be essential for the analysis since a broader view of social construction will be applied for the analysis.

i. All writings are critical towards what we take the world around us to be. They represent an opposition to empiricism that the characteristics of the world can be revealed through observations.

ii. Different authors of a social constructionist view agree on the fact that concepts and categories used are culturally and historically dependent and specific to the context.

iii. Another common characteristic is the belief that the knowledge of the world is

constructed by people in daily conversations. Because of that social interaction

and language is especially interesting to authors of social construction.

Language is then seen as a form of social action because the world, concepts and ideas get constructed by individuals through the use of language.

iv. Because human beings use language to construct the world around them, certain constructions preserve certain patterns of social action and vice versa exclude others. This selection is influenced by power relations since they in the end determine what is wanted in a society and what is not allowed or wanted by it.

The last theme (iv.) is influenced by Foucault and his work on power and knowledge discourse. The way we think and talk about people determines how we treat them which always entail power relations and power imbalance. Foucault describes this as discourse then because it is constituted by language and symbolic systems (Burr, 2003).

The following questions and findings arise in regards to the research objectives and research questions when reading about these four key assumptions:

i. One has to be critical of one’s own assumptions who these ‘antisocial’ and

‘deviant’ youth are, what they need and what they are capable of in their development.

ii. Are these youth then aware of the categories they’re placed in; do they resist against it; do they adhere to it?

iii. If language is important in social construction what words do social workers or others use to describe them?

iv. Can the difference in findings in effectiveness studies in the U.S. and Europe be explained by a different construction of the target group?

The answers to these questions can in an ideal case be found through analysis of the elicited data.

What can be learned from this account then for social work practice? In a way a connection can be drawn to the research of Tighe et al (2012). They touched on that by concluding that through MST youth was able to see the implications of their actions and effect they have on others. This insight can be seen as an important step towards changing and creating behaviour by them which are not accepted in their society, context or personal environment.

3.2 Construction of ‘clienthood’ in social work

In line with the search for literature and relevant articles in the field of social construction and social work, the expression of constructing clients in social sciences arose. When however searching for the terms ‘clientization’ / ‘client hood’ in different databases to find out its origins not enough valuable hits were found to define the concepts properly. There are many different ways how social work professional name, label or call the people they work with. A detailed discussion about the formation of different concepts in social work history will however not be of further interest for this research since the focus is on how the ones being labelled experience or perceive this name-giving. Applying the angle of social construction offers different views and ideas on how the subjects of social work practice are being constructed in different settings. In the process of social reality varying concepts of client hood or clientization are being constructed (Hall, 2003; Gubrium et al, 2013; Witkin, 2012, Baruch, 2007). Especially the construction of deviant youth or the construction of youth as risky business is becoming more and more apparent in social research when doing a key word search in social science databases available at the University of Göteborg for ‘social construction*’ and ‘youth’.

Hall et al (2003) identify terminological pressure when it comes to different concepts

of ‘clients’ and clienthood throughout the history of social work practice. The authors state

that the multiplicity of concepts, especially of the concept ‘client’ has mainly attracted negative connotations and is mostly regarded in literature as a stigma which is denying the clients’ autonomy. As a solution of the debate in social work, on how to name or label the

‘clients’, they offer a way out of this discussion for social workers. Social work professionals have to be made aware of their participation in governmentality (this concept will later be explained within the theoretical framework) and of issues that are related to their social work and personal identity (Hall et al, 2003; Gilbert & Powell, 2010; Foucault, 2008). Interestingly enough when asking ‘clients’ directly about the term which should be used to label them, 40

% of the participants in a focus group in the UK preferred to be called ‘client’ (Heffernan, 2009). The other 60 % had different and varying preferences. These findings contrast sharply with findings in the literature mentioned by the authors above. The discourse on language and labelling clients is of the opinion that the term should not be used whereas clients themselves don’t mind to be called ‘client’. These findings can also be supported by findings in this research.

How much this discussion on how to correctly name your clients and use the language associated with it is ‘just’ a discourse in social work professionals mind or is truly based on clients demand for a different term needs to be investigated. What is worthy to note is that social reality is something people negotiate when they meet, interact, fight or talk and through that construct different interpretations of it. The language used by them to do so can then be seen as an action to produce reality in and by itself and not the other way around. One can therefore conclude with a reference from Hall et al (2003: 19): “It matters how client categories are constructed in social work interaction: categories have real consequences for people’s lives.” The construction of categories and identity by youth in MST treatment is therefore important to be looked upon since only when social workers are aware of the construction of different realities from a client’s perspective can they really involve them into the construction of ‘their’ service.

When it comes to service user’s involvement in social work practice the discussion centres on different meanings and impacts of involvement and that the concept cannot be monopolised on one way of thinking (Evers, 2006; Beresford & Croft, 2004). Based on these authors the combination of concepts is needed that includes different roles of users as citizens with entitlements, consumers and co-producers. Heffernan (2009) connects and reflects this idea in her demand to respect citizenship rights of people and the fact that they have the right to be informed and included in services targeted towards them. She demands that involvement always has to be from the point of view of people categorized as service users since in her findings the discrepancy on what name to use to label people between the people themselves and the social work professional is apparent. The ‘service users’ perceived the term ‘user’ as to broad, anonym and as a reflection of an act which is voluntary and where they can chose.

These are almost exactly terms being used in social science in favour of calling people ‘users’

because the voluntariness of participation should be highlighted as well as the avoidance of marginalisation. This scrutinizes the fact if any ‘service user’ was ever included in constructing this term? For social work to be more emancipatory the profession itself has to connect more and develop closer links with its service users and their organizations and movements. Beresford & Croft (2004: 65-66) demand a form of ‘community control’ because

“[…] without the control of service users, workers and other local people, social work will be an essentially controlling rather than liberating activity.”

3.3 Construction of ‘deviant’ identities in social science discourse

The leading question for this paragraph was to find out how youth is portrayed in current

social work practice or social science literature and how they can or are involved in the

construction of practice then. As already mentioned a keyword search revealed headlines of

articles or books such as “Social construction of deviant identities […]” (Robinson, 2010),

“Young people, risk taking and risk making […]” (Sharland, 2006) or “[…]

deproblematization of troubled lives” (Vitus, 2014). Different articles showed that youth have been identified in western society as a social problem throughout history. Youth have been constructed as a problem and as risky not only to themselves but to society (Clarke, 2008;

Sharland, 2006; Smith, 2003). Some of these youth then become the centre of selective attention by the state and get a distinctive social character assigned which marks them as troublesome by social policy and therefore in need of control. Clarke (2008) calls this a construction of “double dynamic” (Clarke, 2008: 307) – youth problem and problem youth.

This can be connected to Foucault’s concept of governmentality that particular groups are identified as being ‘at risk’ and have to be managed, observed and disciplined. Where they fail to meet standards by the respective society more coercive disciplinary techniques are being used (Sharland, 2006; Smith, 2003). Even though youth seems to be labelled ‘being at risk’ there is according to Sharland (2006) a shortage of work done on youth and risk or even of youth as an own category. In the growing separation of service for children from services for adults the category youth falls in between. This has been noted by the researcher as well when trying to find a coherent term for the age group 15 to 17 years old used in this research.

There seems to be no specific definition how to call the group of people between twelve and

17 years old which are labelled as children by the UNCRC but have however such different

attributes than the age group one to six for example. Especially since adolescence is an

intense period in a person’s live where major changes in the internal self are negotiated with

expectations of the external world (Sharland, 2006). Other authors have researched recently

how youth is experiencing social services or the stereotyping from outside and came to the

conclusion that youth tries to take over their given external identities by talking in “system –

language” (Vitus, 2014: 97; McPhail, 2010). System – language refers to the language and

concepts used in the welfare system to label or categorize people. Since a combination of

narrative and thematic analysis will be used in this research it will be interesting to see if this

phenomenon can be found in the data of semi-structured interviews.

4. Theoretical framework

Reflecting and investigating about the nature and the purpose of a theoretical framework brings a set of highly varying definitions about what a theory even is (Bryman, 2012; Gilbert 2008; Payne, 2005). However what seems to be consistent is that it is a tool to understand the social world around us that can be best summed up in the following quote: “A theory is an organised statement of ideas about the world.” (Payne, 2005: 5). Applying theory therefore is needed to understand the data elicited in research process in relation to the context it exists in.

Theories to better understand data collected through semi-structured interviews were chosen based on their link to the research questions and objectives.

The concept of power defined by authors such as Steven Lukes (2005), Nikolas Rose (1999) or Michel Foucault (1991, 2008) will be used to investigate the relationship between social work professionals and service users in an intensive treatment method like MST. The concept of power will further be applied when it comes to the use of language and categorization in social work and the society it is practiced in. Theories of social construction and clientization are then applied to better understand the construction of social work practice and its clients. Not part of this research will be the discussion whether to use the term client, service user or patient even though it might have an important indirect influence on how youth sees themselves in the treatment process.

4.1 Theories of power relevant in social work

“Power, of various kinds, exercised and available in different ways, is one of the factors in understanding how social work meets its claim.” (Payne, 2006: 139)

To begin with this statement by Payne (2006) is summing up the importance of considering the concept of power in analysing social work practice and how interventions by social work practice affect service users.

Smith (2008) concludes that power is conceptualized in three different modes: the personal aspect of power that affects our quest for identity; the positional aspect which is affecting our social position or interactions with others and the relational aspect of power which depends on the situation and the nature of exchange. The relationship between a social worker and their client is thus influenced by all three modes. Because power is experienced and exercised on a different number of levels which are interconnected the use of an ecological model in the MST approach seems to be useful to be able to address power imbalance on various levels. The clients or service users play a key role in determining and shaping power relations which affect social work interventions. The power service users hold are strategies such as compliance, non-cooperation, resistance or cooperation they can apply, which in turn can determine the effectiveness of an intervention. The role of the social worker then is to provide the service user with the tools to make decisions and start negotiating the role they play in creating successful interventions (Smith, 2008). Not only can these internal influences like strategies of service users shape practice also external influences such as the media in a country or the law play a key role. Unfortunately the media in most European countries can be responsible for a negative picture of social work and can draw a falsified picture of deviant youth for example (Robinson, 2010).

The search for information on power in social work setting was started by looking up

the word ‘power’ in the online edition of the Oxford Dictionary of English (ODE). Seven

definitions can be found under the term ‘power’ from “the ability or capacity to do something

or act in a particular way”; “the capacity or ability to direct or influence the behaviour of

others or the course of events” to “physical strength and force exerted by something or

someone” (Stevenson, 2010). The three mentioned definitions mainly reflect a liberal

conception – an individual’s self-determined conflict and interests – as well as a radical

conception of power where the wants and desires of individuals are manipulated and power is being exercised. The most prominent author of a radical approach to power by Steven Lukes (2005) will be explained in the following chapter 4.1.1.

Throughout the historical debate on power in social sciences three themes emerged about the derivation of power according to Payne (2006: 136): power deriving from professional role and personal influence, power from social authority and power from law.

Social work practice incorporates all three derivations and therefore has to be kept in mind when analysing power relations. Further on in this chapter the work of Lukes (1975, 2005) as a representative of radical power conceptions will be used as a base to investigate the importance of Foucault’s and Rose’s ideas on power and identity to this research. All three authors give valuable incitements to analyse the collected data in regards to youth’s construction of identity within relationship that are shaped by power imbalance.

4.1.1 The work of Steven Lukes and the influence on radical social work

Power as a concept had always been around in the history of social sciences. It first became apparent in the history of debate as an authority problem, then as a power problem and later as the empowerment problem (Payne, 2006). The radical view of Lukes can be classified within the second phase – power problem. Digeser (1992) describes four faces of power in his article

‘The Fourth Face of Power’. He situates Lukes within the third face since he describes it as a form of power where desires and wants are manipulated and power is therefore being exercised. The first and second face are described as a liberal conception of power by Digeser (1992) whereas Foucault is then mentioned as the fourth face since it is significantly different from the first three faces.

Lukes sees power as a capacity to influence and achieve others compliance with one’s own wants and wishes. The capacity to influence others can then come from a variety of sources like personal qualities or resources to apply coercion (Lukes, 2005; Payne, 2006).

Radical social work relies on a Marxist analysis of class power where social control is being exercised on behalf of capitalism to be able to fulfil the needs for production. Social work in the radical conception of power is then part of the capitalist system to maintain power and clients are left in a less powerful position to be able to achieve capitalist power. The work of Lukes (1974; 2005) had been an important foundation for the emergence of anti-oppressive practice, anti-discrimination practice, feminist analysis and empowerment practice. Lukes relates the exercise of power to a concept of interests because the power relations depend on the individuals involved in it, how they serve their purpose and how they perceive them. An important part in his idea is that the power relationships heavily depend on identities the involved actors hold and how these are constructed and changed (Smith, 2008). This personalized aspect of power is crucial in understanding his ideas because it raises the question whether an individuals or a group’s identity is constructed by themselves or if it is defined by others? Can individuals define their identity truly self or is it ascribed by others?

Lukes further on argues that in society a particular image of a group or an individual is

promoted by a dominant group conveying a preferred norm of assigned characteristics and

properties to that group / individual. Result of this is that some groups are being devalued

whereas others become more influential. By that certain forms of identity become rejected or

not recognized creating a feeling of ‘otherness’. These processes can significantly influence

individuals’ negotiation of their own identities. How do youth who are assigned the attributes

of ‘antisocial’, ‘deviant behaviour’ or ‘in need of treatment’ then create their identities and

how does it influence relationships they have outside of family and therapy? When looking at

the definition of the word ‘deviant’ it becomes apparent that already the word itself includes

the notion of ‘otherness’ and not normal since it says in the online edition of the Oxford

Dictionary of English (Stevenson, 2010) under the word deviant “departing from usual or